The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long-term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?
Ankle ulcer that is healing slowly.
History of alcohol abuse and cigarete smoking.
Recent weight gain of twenty pounds.
Newly prescribed antihypertensive medication.
The Correct Answer is D
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
A. An ankle ulcer that is healing slowly is not a major risk factor for falls and may not affect the client's mobility or balance.
B. History of alcohol abuse and cigarette smoking is not a major risk factor for falls unless the client is currently intoxicated or has a chronic lung disease that impairs oxygenation or cognition.
C. Recent weight gain of twenty pounds is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.
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Related Questions
Correct Answer is C
Explanation
Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.
The other options are not correct because:
A. Instructing the mother to play with the child for stimulation and distraction may worsen the child's condition, as it can increase his respiratory demand and anxiety.
B. Administering a dose of acetaminophen as needed may help reduce fever or pain, but it does not address the underlying cause of croup or improve airway patency.
D. Encouraging the child to drink adequate amounts of fluids may help prevent dehydration and thin the secretions, but it does not relieve the inflammation or narrowing of the airway.
Correct Answer is B
Explanation
Choice A rationale:
Asking the client to describe the intensity of the eye pain using the numerical pain scale is not the most relevant action in this situation. The client's statement indicates a misconception about the purpose of pilocarpine eye drops, so addressing this misunderstanding should be the focus.
Choice B rationale:
Reminding the client that the action of the eye drops is to decrease internal eye pressure is the appropriate action. Pilocarpine eye drops are used to treat glaucoma by reducing intraocular pressure, not to anesthetize the eye.
Choice C rationale:
Documenting in the chart that the client understands the action and use of the eye drops might be necessary but should not be the first action taken. The priority is to correct the client's misunderstanding about the eye drops.
Choice D rationale:
Clarifying with the client that eye pain in glaucoma is uncommon, so drops are rarely needed, is not accurate. While eye pain might not be a common symptom of glaucoma, pilocarpine eye drops are specifically used to manage intraocular pressure and are not intended to address eye pain.
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